Practice Portfolio of Evidence PART B: Clinical Encounter Analysis

This document provides an analysis of a critical clinical encounter in the emergency department, focusing on the nursing actions taken to address the patient's condition. It highlights the importance of communication and documentation in patient care and discusses the potential risks and outcomes associated with certain medications. The document also suggests the use of a communication tool called SBAR (Situation, Background, Assessment, Recommendation) and the need for training and technological reliance for better documentation.

CNA344: Becoming a RN: Practice consolidation
Practice Portfolio of Evidence PART B: Clinical Encounter Analysis
Consider the
patient
situation/context
Provide an overview
of the encounter.
What happened,
how it occurred, etc
what was it that
alerted you to that
fact that you needed
to take action in the
encounter.
(150 words)
A patient was admitted to the emergency department with severe chest pain, sweating, body discomfort, palpitations, breathlessness
and light-headedness. He was immediately put on supplemental oxygen therapy though nasal cannula and an Electrocardiography was
performed to monitor the patient’s heart conditions. The patient was administered with sublingual nitroglycerin in conjunction with
morphine to relieve the severe chest pain. The patient was given ticagrelor, a platelet aggregation inhibitor to prevent any blood
clotting. A mild dose of aspirin was administered along with ticagrelor. Two hours post administration, noticeable drop in blood
pressure was observed followed by severe nose bleeding; difficulty in breathing was aggravated. Monitoring the ECG showed a
significant drop in pulse rate or bradycardia. Severe nose bleeding, bradycardia, dizziness and breathing difficulties and worsening
patient condition post administration of pain relievers and ticagrelor raised an alert signal which brought me, a registered nurse by
profession into action.
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Review: what key
information was
already available to
you and how did this
influence your
thinking? (eg:
handover, history,
charts, result of test,
assessments,
medical orders
etc.).
(150 words)
Gather:
What was the new
information you
gathered from
Review: In response to the patient’s critical condition, the patient’s past medical records and the family history of cardiac details are
taken into consideration. The ECG reports were available which were assessed for specific criteria. Shift nurses were assigned for the
patient’s monitoring and diagnosis purpose. The clinical handover reports of the shift nurses were available for consideration. From
the patient provided medical history records, the patient had allergy from aspirin so aspirin as analgesic was not administered; instead
morphine was administered to relieve pain. The patient had reported continuous chest pain and discomfort for the last 24 hours;
increase in severity of pain caused him to seek for emergency help. Prior cardiac occurences have been mentioned in the patient’s
medical history. The patient’s past cardiac reports showed an administration of ticagrelor to prevent blood clotting. The medications
and diagnosis have been provided according to the patient provided medical details.
Relevant medications (where relevant): (not included in word count)
Gather:
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additional
assessment?
(150 words)
Dot points are fine
for this section
Recall:
Recall and apply
your existing
knowledge to the
above situation to
ensure you have a
broad understanding
of what is/may be
occurring before
proceeding with the
Additional assessment of the patient made certain revelations. Drug treatment was intended to minimize the patient discomfort;
however, the patient responded with severity post drug treatment. The symptoms with which the patient was admitted were elevated,
which was a concern for consideration. The patient’s medical records revealed that the patient had allergy due to aspirin. The patient
had recurrent hypertensive episodes. The patient showed a significant drop in pulse rate of 40 beats per minute compared to normal
pulse rate of 80-120 beats per minute. The blood pressure showed an elevation compared to before admission. Reddened and itchy
rashes were found in certain areas of patient’s body; a mild swelling of the face was noticeable. On assessment, the patient reported
that he suffered from constipation and did not have any appetite. A feeling of nausea and vomiting accompanied the patient’s
symptoms. The patient showed an increased level of anxiety and impatience.
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rest of the cycle.
What was telling
you that the
encounter was
presenting you with
a problem that
required resolution?
(200 words)
Use scholarly,
evidence-based
literature/clinical
guidelines and/or
policy/NSQHS
materials to
substantiate your
Recall: Administration of the drugs namely nitroglycerin, morphine, ticagrelor had been in accordance with the patient’s past medical
reports. However, while assessing the diagnostic reports and test results, the dosage of the drugs may play a crucial role in worsening
the conditions of the patient. According to research evidence, sublingual nitroglycerin may not pose any negative effect on the
patient’s condition (Takx et al. 2015). Nitroglycerin promotes dilation of cardiac vessels and restores the cardiac requirement of
oxygen. The therapeutic use of morphine as pain reliever in myocardial infarction has not gained promising results due to dosage
errors. High dosage of morphine is associated with various side-effects when used as a pain reliever. The patient’s symptoms of
increased dizziness and difficulty in breathing post administration of morphine suggest as possible signs of overdose of morphine
(Parodi et al. 2015). Ticagrelor administration is associated with side-effects even in normal dosage administered. Severe nose
bleeding observed in the patient was a negative response due to side-effects. Shallow breathing rates observed post administration
may also be an effect of overdose of ticagrelor (Gaaubert et al. 2014). Monitoring the patient’s conditions and assessing the diagnostic
reports, the dosage administration of morphine and ticagrelor required critical concern in the patient’s case. Severity of the patient
condition post drug treatment was the turning point of my understanding.
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discussion
5

6

Process
Information
Interpret, relate and
infer from the
information
gathered to
demonstrate an
overall
understanding of the
clinical encounter to
determine the two
main nursing
problems.
(400 words)
Interpret, Relate and Infer:
In the emergency department, many nurses are involved in patient diagnosis, treatment, management and follow-up care provision.
The handover responsibilities between nurses are main areas of concern during patient management. Communication plays a
significant role between patient and nurse relation in providing better care and patient outcome. In the reported patient’s case, nurses
involved in immediate care provision during admission in the emergency department were assigned with the diagnosis of the patient.
Another group of nurses were involved in recording the diagnostic results. The medications for pain relieving and patient management
were provided by the shift nurses. A new group of shift nurses were assigned with the follow-up care for the patient post drug
treatment. In all these handover responsibilities, communication forms a significant part; communication failures and
misunderstandings during clinical handover pose an unpredictable care and patient outcome. Several handovers at diverse time points
created communication gap between nursing professionals in emergency department and the shift nurses. Exchange of clinical
information between shift nurses and follow-up nurses could have been resulted in misunderstandings of bedside handover
responsibilities. Time to time clinical follow-up required to be taken by the follow-up nurses post administration of morphine in order
to check for the patient’s response to the treatment. This post treatment follow-up may not have been taken in timed manner; severity
of the symptoms was a response to failure of follow-up care. Investigating the patient’s reports involved clear communication
between shift nurses; conveying of important clinical information relative to the changes in patient’s conditions in follow-up
procedure resulted in communication gap. Efficient monitoring was not provided during the two hours post drug administration. The
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Predict
What could/would
have happened in
your encounter if
you were to have
taken NO action and
why?
(100 words)
Use scholarly,
evidence-based
literature/clinical
guidelines and/or
policy/NSQHS
materials to
substantiate your
nursing care did not involve the patient in decision making; as a result, the patient responded with allergic reactions even in mild
dosage of aspirin administration. That the patient was allergic to aspirin was not known from the past medical records; there was a
lack of awareness from the patient. The nurses lacked proper knowledge about the side-effects of morphine and ticagrelor; thus the
side-effects were predominant as patient’s response after drug treatment. The nursing knowledge about the side-effects and dosage
composition of drugs need to be a priority concern while attending to the patients.
Predict:
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discussion
Overdose of morphine without any nullifying medication would have resulted in mortality of the patient. The naloxone is a
medication administered at frequent regular time intervals to mitigate the adverse effects of the morphine overuse. If the intravenous
administration of naloxone was not given to the patient, the patient would have died due to increased difficulty of breathing (Kim and
Nelson 2015). In case of nose bleeding, the patient is made to sit upright and supported so as to breathe through open mouth. Nasal
tampons coated with bacitracin was provided to stop nose bleed. The patient was administered 2% oxymetazoline (Morgan and
Kellerman 2014). Excessive nose bleeding for continued hours would have resulted in fatal outcomes, even leading to death.
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Identify the
Problem/s
List in order of priority two key nursing problems that required resolution (not included in word count)
Problem 1 Communication problem and misunderstanding during verbal exchange during clinical handover responsibilities.
Problem 2 Absence of well-structured written documentation
Establish Goals &
Take Action
Work through the
two nursing
problems identified
and establish one
goal and then
rationalise with
scholarly, evidence-
based
Problem 1 Goal Related nursing actions Rationale
Communication and
incomplete verbal exchange
of information between
nurses
Improved communication
between shift nurses and
clinicians with improved
patient safety and patient
outcome.
Implementing SBAR
clinical handoff
communication tool
Evidence based nursing
strategies show that the
clinical handoff tool (SBAR
communication tool) during
clinical transfer of
responsibilities provide an
improved communication
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literature/clinical
guidelines and/or
policy/NSQHS
materials the related
nursing actions you
did/would undertake
(125 words for each
rationale section).
Other sections not
included in word
count.
between shift nurses and
clinicians (De Meester et al.
2013). SBAR
communication tool
provides the framework for
a well structure
communication between
nurses and physicians. This
tool provides a detailed
information on Situation,
Background, Assessment
and Recommendation based
on the patient condition. It
provides a clear and succinct
communication strategy.
The mnemonics can be used
to remember the critical
steps of care provision. The
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well-structured format
provides a logical and easy
to follow process and
minimizes communication
gap during transfer of
clinical responsibilities
(Randmaa et al. 2014). This
communication tool
prevents the risk of missing
any critical clinical
information.
Problem 2 Goal Related nursing actions Rationale
Absence of written
documentation between
clinical handover
responsibilities
Improved patient safety and
efficient care provision.
Training to nurses, involving
more nurses increase the
number of nursing staff.
Evidence-based research
shows that the clinical
documentation forms an
important part of patient
care services. Training the
nursing officials on
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standardised documentation
formats would help to keep
a record of the patient
details (Munroe et al. 2013).
Technological reliance for
documentation purpose
would save a lot of time,
thereby the nurses could
devote more time to patient
centred quality care. Clinical
documentation leads to
accuracy of providing care
services and intervention
methods to patients (Kern et
al.2013). As a result, the risk
of faulty treatment or
medications gets reduced.
This impacts positively on
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the medical finances;
unreasonable medical billing
is prevented. Technological
training and involvement of
more number of nurses into
documentation would
maintain the patient records
in a detailed and safe format
which can be retrieved as
and when required and
thereby referred for future
diagnosis (Khali et al. 2014).
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Evaluate outcomes
Evaluate the
outcomes of your
clinical encounter
including
effectiveness of the
care provided with
supporting
evidence-based
literature
(100 words)
*Do not ‘reflect on
new learning’ in this
section. This will
occur in your next
assessment (Part C).
The patient showed an improvement in the health condition; the nauseatic feeling and vomiting tendencies have been cured. The nose
bleeding stopped and the gasping breathlessness of the patient was improved. The heart rate was restored to normal threshold level;
the itchy painful rashes due to allergic reactions of aspirin were dissolved and the patient discomfort was relieved comparatively. My
frequent monitoring of the patient’s condition in response to naloxone administration. The patient gained stability in condition and
consciousness was restored. A well-structured diagnostic plan and documented follow-up method would improve the patient care
(Guerrasio and Aagaard 2014).
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References:
De Meester, K., Verspuy, M., Monsieurs, K.G. and Van Bogaert, P., 2013. SBAR improves nurse–physician communication and reduces unexpected death: A
pre and post intervention study. Resuscitation, 84(9), pp.1192-1196.
Gaubert, M., Laine, M., Richard, T., Fournier, N., Gramond, C., Bessereau, J., Mokrani, Z., Bultez, B., Chelini, V., Barnay, P. and Maillard, L., 2014. Effect of
ticagrelor-related dyspnea on compliance with therapy in acute coronary syndrome patients. International journal of cardiology, 173(1), pp.120-121.
Guerrasio, J. and Aagaard, E.M., 2014. Methods and outcomes for the remediation of clinical reasoning. Journal of general internal medicine, 29(12), pp.1607-
1614.
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Kern, L.M., Malhotra, S., Barrón, Y., Quaresimo, J., Dhopeshwarkar, R., Pichardo, M., Edwards, A.M. and Kaushal, R., 2013. Accuracy of electronically
reported “meaningful use” clinical quality measures: a cross-sectional study. Annals of internal medicine, 158(2), pp.77-83.
Khalil, H., Cullen, M., Chambers, H., Steers, N. and Walker, J., 2014. Implementation of a successful electronic wound documentation system in rural Victoria,
Australia: a subject of collaboration and community engagement. International wound journal, 11(3), pp.314-318.
Kim, H.K. and Nelson, L.S., 2015. Reducing the harm of opioid overdose with the safe use of naloxone: a pharmacologic review. Expert opinion on drug
safety, 14(7), pp.1137-1146.
Morgan, D.J. and Kellerman, R., 2014. Epistaxis: evaluation and treatment. Primary Care: Clinics in Office Practice, 41(1), pp.63-73.
Munroe, B., Curtis, K., Considine, J. and Buckley, T., 2013. The impact structured patient assessment frameworks have on patient care: an integrative
review. Journal of Clinical Nursing, 22(21-22), pp.2991-3005.
Parodi, G., Bellandi, B., Xanthopoulou, I., Capranzano, P., Capodanno, D., Valenti, R., Stavrou, K., Migliorini, A., Antoniucci, D., Tamburino, C. and
Alexopoulos, D., 2015. Morphine is associated with a delayed activity of oral antiplatelet agents in patients with ST-elevation acute myocardial infarction
undergoing primary percutaneous coronary intervention. Circulation: Cardiovascular Interventions, 8(1), p.e001593.
Randmaa, M., Mårtensson, G., Swenne, C.L. and Engström, M., 2014. SBAR improves communication and safety climate and decreases incident reports due to
communication errors in an anaesthetic clinic: a prospective intervention study. BMJ open, 4(1), p.e004268.
Raymond, M. and Harrison, M.C., 2014. The structured communication tool SBAR (Situation, Background, Assessment and Recommendation) improves
communication in neonatology. SAMJ: South African Medical Journal, 104(12), pp.850-852.
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Takx, R.A., Suchá, D., Park, J., Leiner, T. and Hoffmann, U., 2015. Sublingual nitroglycerin administration in coronary computed tomography angiography: a
systematic review. European radiology, 25(12), pp.3536-3542.
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